ATI Fundal Assessment

A nurse is caring for a client who is 8 hours postpartum. The nurse palpates the fundus at 2 fingerbreadths above the umbilicus and deviated to the right. Which of the following actions should the nurse take first? Assist the client to void. Administer analgesics. Pour water from a squeeze bottle over the client's perineum. Teach the client relaxation exercises.

Assist the client to void The nurse should assist the client to void either in the bathroom or into a bedpan if the client is unable to ambulate. Bladder distention may cause uterine atony and excessive bleeding; therefore, the priority action is to assist the client to void to facilitate emptying of the bladder.

A nurse is caring for a client who is 8 hours postpartum and begins to hemorrhage. Which of the following actions should the nurse take? Massage the client's fundus. Evaluate the client's temperature. Insert a urinary catheter. Draw a CBC.

Massage the client's fundus The greatest risk to this client is injury from hemorrhage. The nurse's priority intervention is to prevent excessive bleeding. The nurse should massage the uterus to expel clots to allow the uterus to contract. Uterine massage facilitates improved uterine tone.

A nurse is caring for a client who is experiencing postpartum hemorrhage and has a prescription for methylergonovine. Which of the following conditions is a contraindication for this medication? Gestational diabetes mellitus Preeclampsia Asthma Cholecystitis

Preeclampsia The nurse should identify preeclampsia as a contraindication for methylergonovine. Other contraindications include hypertension and cardiac disease. Methylergonovine is a uterotonic medication to manage postpartum hemorrhage. The nurse should notify the provider of the contraindication.

A nurse is caring for a client who is 2 hours postpartum. Which of the following factors should the nurse identify as a risk factor for postpartum hemorrhage? Oligohydramnios Intrauterine growth restriction Primigravida Prolonged labor

Prolonged labor Prolonged labor is a risk factor for the development of postpartum hemorrhage. Prolonged labor results in stimulation of the uterine muscle for an extended amount of time, which may cause uterine atony and postpartum hemorrhage.

A nurse is collecting data from a client who is postpartum and has saturated 4 pads in 1 hour. Which of the following findings is a manifestation of hemorrhagic shock? Polyuria Bradycardia Rapid shallow respirations Capillary refill less than 2 seconds

Rapid shallow respiration's